Nokea
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
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A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
- A. The client is grasping his abdomen
- B. The client is hyperventilating
- C. The client is coughing
- D. The client cannot speak
Correct Answer: D
Rationale: Inability to speak is a sign of complete airway obstruction requiring abdominal thrusts. Coughing indicates partial obstruction and does not require immediate thrusts.
A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?
- A. Dilated pupils
- B. Dysrhythmias
- C. Diarrhea
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B: Dysrhythmias. Straining while defecating can increase intra-abdominal pressure, leading to a vagal response that triggers dysrhythmias in susceptible individuals. This can be particularly dangerous for older adults with underlying heart conditions. Dilated pupils (choice A) are not directly related to straining during defecation. Diarrhea (choice C) is the opposite of constipation and is not a common consequence of straining. Gastric ulcers (choice D) are typically caused by factors such as H. pylori infection or NSAID use, not straining during defecation.
A nurse is assisting with speaking in front of a group of nurses about new guidelines to prevent pressure ulcers. Which of the following actions by the nurse demonstrates confidence?
- A. The nurse stands tall before talking.
- B. The nurse paces back and forth while making the speech.
- C. The nurse looks down at her notes for the duration of the talk.
- D. The nurse taps her foot repeatedly during the speech.
Correct Answer: A
Rationale: Standing tall with good posture conveys confidence and authority while speaking.